Hanswerner Bause

Quality indicators in intensive care medicine: why? Use or burden for the intensivist.

In order to improve quality (of therapy), one has to know, evaluate and make transparent, one’s own daily processes. This process of reflection can be supported by the presentation of key data or indicators, in which the real as-is state can be represented. Quality indicators are required in order to depict the as-is state. Quality indicators reflect adherence to specific quality measures. Continuing registration of an indicator is useless once it becomes irrelevant or adherence is 100%. In the field of intensive care medicine, studies of quality indicators have been performed in some countries. Quality indicators relevant for medical quality and outcome in critically ill patients have been identified by following standardized approaches. Different German societies of intensive care medicine have finally agreed on 10 core quality indicators that will be valid for two years and are currently recommended in German intensive care units (ICUs).

The German quality indicators in intensive care medicine 2013--second edition.

Quality indicators are key elements of quality management. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2010 were recently evaluated when their validity time expired after two years. Overall one indicator was replaced and further three were in part changed. The former indicator I “elevation of head of bed” was replaced by the indicator “Daily multi-professional ward rounds with the documentation of daily therapy goals” and added to the indicator IV “Weaning and other measures to prevent ventilator associated pneumonias (short: Weaning/VAP Bundle)” (VAP = ventilator-associated pneumonia) which aims at the reduction of VAP incidence. The indicator VIII “Documentation of structured relative-/next-of-kin communication” was refined. The indicator X “Direction of the ICU by a specially trained certified intensivist with no other clinical duties in a department” was also updated according to recent study results. These updated quality indicators are part of the Peer Review in intensive care medicine. The next update of the quality indicators is due in 2016.

Peer reviewing critical care: a pragmatic approach to quality management.

Critical care medicine frequently involves decisions and measures that may result in significant consequences for patients. In particular, mistakes may directly or indirectly derive from daily routine processes. In addition, consequences may result from the broader pharmaceutical and technological treatment options, which frequently involve multidimensional aspects. The increasing complexity of pharmaceutical and technological properties must be monitored and taken into account. Besides the presence of various disciplines involved, the provision of 24-hour care requires multiple handovers of significant information each day. Immediate expert action that is well coordinated is just as important as a professional handling of medicines limitations. Intensivists are increasingly facing professional quality management within the ICU (Intensive Care Unit). This article depicts a practical and effective approach to this complex topic and describes external evaluation of critical care according to peer reviewing processes, which have been successfully implemented in Germany and are likely to gain in significance.

Voluntary peer review as innovative tool for quality improvement in the intensive care unit--a retrospective descriptive cohort study in German intensive care units.

Introduction: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports. Methods: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs – representing over 300 patient beds – had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. Results: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interesting Conclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.

Abschätzung akuter linksventrikulärer Nachlaständerungen

ZusammenfassungBei 21 beatmeten Intensivpatienten wurden akute linksventrikuläre Nachlaständerungen unter Noradrenalin oder Nitroglyzerin mittels der transösophagealen Echokardiographie (TEE) überwacht. Mit der TEE wurde die linksventrikuläre endsystolische Myokardspannung (endsystolischer „wall stress``, WS) im zweidimensionalen Verfahren (2D) und im M-mode-Verfahren (M) bestimmt und diese beiden Nachlastparameter mit dem systemischen Gefäßwiderstand (SVR) verglichen. Änderungen der linksventrikulären Nachlast wurden von allen drei Kenngrößen in der Richtung übereinstimmend erfaßt, in Relation zur WS2D jedoch durch die WSM und den SVR um 15–30% geringer eingeschätzt. WS2D, WSM und SVR korrelierten untereinander nicht. Der berechnete geometrische Faktor der WS2D reflektierte die Größenveränderung des linken Ventrikels unter der Behandlung sowohl mit Noradrenalin als auch mit Nitroglyzerin, der geometrische Faktor der WSM dagegen nicht. Aus den Ergebnissen ist zu schließen, daß die WS2D ein besserer Parameter für die Abschätzung akuter linksventrikulärer Nachlaständerungen ist als die WSM. Die Abschätzung der linksventrikulären endsystolischen Myokardspannung mit dem SVR ist nicht möglich.AbstractLeft ventricular afterload is most accurately represented by left ventricular end-systolic wall stress, but in clinical practice is commonly estimated by the systemic vascular resistance (SVR). End-systolic wall stress can be derived from M-mode and two-dimensional (2D) echocardiograms in combination with systolic arterial pressure (SAP). We tested transoesophageal echocardiography for the assessment of acute left ventricular afterload alterations in ventilated patients requiring cardiovascular support with noradrenaline or nitroglycerine. Method. With approval from the local ethics committee, we studied afterload alterations in 11 hypotensive patients who were treated by increasing the dosage of IV noradrenaline by 2–5 μg/min in order to raise mean arterial pressure (MAP) by 20 mmHg. In another 10 patients with MAP over 95 mmHg, nitroglycerine was raised from 2 to 4 mg/h, aiming at a 20 mmHg MAP reduction. MAP and SAP were monitored via a radial artery cannula, cardiac output (CO) was measured with the thermodilution technique using a Swan-Ganz catheter, and SVR was calculated from CO, MAP, and right atrial pressure. M-mode and 2D echocardiograms were obtained from the cross-sectional short-axis view of the left ventricle and recorded shortly before and during treatment when MAP had changed by 20 mmHg. Left ventricular total area (TA) and cavity area (A) including the papillary muscles were obtained from end-systolic 2D echocardiograms, while end-systolic internal diameter (ID) and posterior wall thickness (HW) were measured in the M-mode. Wall stress was calculated in the M-mode as: WSM=0.33 · SAP · ID/(HW · (1+HW/ID)), and in the 2D mode as: WS2D=1.33 · SAP · A/(TA-A). Statistics: paired t-test (P<0.05), regression analysis. Results. Afterload alterations were reflected by significant changes of WS2D (―41%, +68%), WSM (―26%, +38%), and SVR (―15%, +50%). WSM and SVR underestimated changes of WS2D by 15%–30%. WSM changes due to SAP rather than to left-ventricular dimensional changes. No correlation was found between WS2D or WSM and SVR. Inter-observer variability for echocardiographic wall stress was reasonable (WS2D 4%, WSM 10%). Conclusions. Acute changes of left ventricular afterload and dimensions were clearly indicated by 2D measurements. As M-mode measures were not conclusive for left ventricular dimensional changes, WSM was not an appropriate parameter for acute afterload alterations. WS2D is an afterload index superior to WSM that cannot be estimated by SVR.

Peer Reviews in der Intensivmedizin

Peer reviewing in intensive care medicine is an evaluation process that promotes a professional understanding of quality and the exchange of experience in intensive care. It will help integrate evidence-based knowledge into the treatment process at an earlier stage and thus improve the quality of intensive care and intensive nursing care. The process is a learning experience for all involved and is highly satisfying to the participants. The exchange of experience is an essential part of quality control.